LOUISIANA INDEPENDENT LIVING ASSESSMENT 3.1 COVER SHEET A. Client Identification

LOUISIANA INDEPENDENT LIVING ASSESSMENT
3.1 COVER SHEET
Assessment
Re-Assessment
Annual
Clients Initials
Date:
Date:
Change
Nutrition Score
ADL
A. Client Identification
12. Are you a Veteran?
1. Name:
(First)
(MI)
(Last)
IADLS
Yes
No
13. Are you a Veteran dependent?
Yes
Maiden Name:
No
B. Emergency Contact
Also Known as:
Primary Physician
2. ID Number
Name
3. Ethnic Race
a. Non-Minority (White, non-Hispanic)
Address
b. Black/African-American
c. American Indian / Native Alaskan
d. Asian
e. White Hispanic
f. Native Hawaiian/Other Pacific Islander
Phone Number
Relative/Friend
Name
Address
Phone Number
g. Other
C. Directions to Home
4. Phone Number
5. Social Security Number#
6. DOB
/
Month
/
Day
D. Does Client live?
Year
1.
Alone
2.
With spouse/partner
3.
With spouse and child
a. Street
4.
5.
With child/children (including adult child)
Information unavailable
b. Town
6.
With others
7. Age
8. Gender
Male
Female
9. Mailing Address
c. State LA
Name of spouse/Partner (Optional)
d. Zip
E. Health Insurance: Do you have?
10. Residence
Yes
a. Street or PO Box
Type
1. Medicare A
b. Town
c. State
No
2. Medicare B
LA
d. Zip
11. Marital Status
a. Single
b. Married
d. Widowed
e. Divorced
3. Medicare D
4. Medigap
c. Separated
f. Not Available
5. Medicaid
6. LTC
7. Other
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Clients Initials
L. Services
F. Do you have prescription drug insurance?
Yes
Yes
No
Assisted Transportation
Case Management
Chore
Congregate Meals
No
G. Client Characteristics
Yes No
a. Abused/Neglected/Exploited
Home Delivered Meals
Homemaker
Date
If yes, Referred to
I&A
Legal Services
b. Disabled
c. Duplicate Mail
Nutrition Education
d. Female head of household
e. Frail
Nutrition Counseling
Outreach
Personal Care
Transportation
Medication Management
Wellness
f. Homebound
g. Medicare Eligible
h. Receiving Social Security
i. State Resident
j. Tribal
NFCSP 1
Other
H. Household Size (entire household)
a.
1 person
b.
2 people
c.
3 people
d.
Want to
Apply
Adult Day Care/Adult Day Health
If no, do you want information on the Senior Rx program?
Yes
No
1 National
Family Caregiver Support Program requires a
different assessment form.
M. Services
Client is placed on waiting list?
4 or more people
I. Monthly Income: (entire household)
SSI
$ 565
or less
1
$ 775
or less
2
$1,040
or less
3
$1,305
or less
4
$1,576
or less
5
$1,836
or less
Yes
No
If yes, list services(s)
N. Interview Questions
Where interviewed: Home
Nursing Home
Other
Hospital
(Specify)
Did someone help client or answer questions
for client?
Yes
No
Helper's Name
Relationship
Communication/Language Assistance needed
for assessment?
Yes
No
Language
J. Donations
Individual has been advised that s/he has an opportunity to
make voluntary and anonymous donations for any service
s/he may receive.
Yes
No
Type of assistance
Assessor:
K. Permission
The client has formally authorized a release of
information.
Yes
No
Agency:
Client signature:
Attach copy of signed and dated authorization.
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Clients Initials
O. Determine Your Nutritional Health.
(Circle your answers and add up your score)
Yes
No
Client has made changes in lifelong eating habits because of health problems.
Client eats fewer than two (2) meals per day.
Client eats fewer than 5 servings of fruits and vegetables
Client eats fewer than two (2) servings of dairy products (such as milk, yogurt, or cheese) every day.
Client has biting, chewing, or swallowing problems that makes it difficult to eat.
Client does not have enough money to buy food most of the time.
Client eats alone most of the time.
Client takes three (3) or more different prescriptions or over-the-counter drugs per day.
Without wanting to, Client has lost or gained ten (10) pounds in the past six (6) months.
Client is not physically able to shop, cook, and/or feed themselves (or to get someone to do it
for them) most of the time.
Client has three (3) or more drinks of beer, liquor, or wine almost every day.
TOTALS
(Add YES and NO columns) for your total nutrition score.
0
COMBINED TOTAL
Record the combined total on the Cover Sheet and the GOEA Score Sheet.
If it is:
0-2
GOOD! Recheck the Nutrional Score at annual review.
3-5
You are at a moderate nutritional risk. Ask your area agency on aging, senior nutrition program,
senior citizens center or health department what can be done to improve your eating habits and
lifestyles.
6 or more
You are at high nutritional risk. Bring a copy of this checklist the next time you see your doctor,
dietician, or other qualified health or social service professional. Talk with them about any
problems you may have. Ask for help to improve your nutritional health.
NOTE: High-risk clients should receive a copy of the scoring sheet and isntructed to give to their physician, caregiver, or family
member for follow-up. High-risk clients should be closely monitored - a six-month review.
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Clients Initials
SECTION 3.2 INTAKE ASSESSMENT
A. Legal Representative
1. Do you have a:
Yes
No
✔
a. Power of Attorney
b. DPOA for Health Care
c. DPOA for Finances
✔
d. Representative Payee
✔
e. Guardian
2. Do you have advanced directives?
If no, do you need information provided about advance directives?
Yes
No
Yes
No
B. Assessment Information
1. Reason for Referral
2. Referred by?
a.
Self
d.
Agency
b.
Family
e.
Other
c.
Hospital
f.
Information unavailable
(Name)
3. Do you live in (Read all choices before recording the answer)
a.
House/mobile home
b.
Private Apartment
c.
Private Apartment in senior housing
d.
Residential care home
e.
Nursing home
f.
Information unavailable
g.
Other
4. How long have you lived at this current residence?
a.
Less than 12 months
b.
1 - 3 years
c.
3 years or more
5. If you moved in the past 3 years, did you live in?
a.
Own home for
months
b.
Residential care home for
c.
Other
months
for
months
d.
Nursing home for
e.
Hospital for
f.
Not applicable
months
months
6. Are you currently employed?
a.
Yes
b.
No
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Clients Initials
7. Are you receiving any of the following services? (Refers to services that may not be funded with GOEA dollars)
Services
Yes
No
Want to
Apply
Services
Yes
a. Attendant services
r. Energy Assistance
b. Medicaid Waiver
c. Homemaker Program
d. Home Health Aide
e. Private Nursing
s. Telephone Reassurance
t. Medicaid
u. SSI
v. Prescription Program
f. Speech Therapy
w. OMB/SLMB
g. Occupational Therapy
h. Physical Therapy
x. Medical Alert
y. Community Services
i. Private Sitter Services
z. Respite Services
j. Emergency Lifeline
1. Hospice Services
k. Senior Companion
2. Rehabilitation Services
l. Weatherization
3. Transportation Services
m. Home Repair
4. Other
n. Support Group
5. Other
o. Adult Day Services
6. Other
p. Commodity Assistance
7. Other
q. Food Stamps
8. Other
No
(Read all choices before recording the answer)
(Arrows and Italics indicate that the question is to be answered by the client only)
8. Do you have any children or other relatives who live nearby (within one hour's drive)?
a.
b.
Yes
No
*9. Do you have contact with:
Yes
a.
Family often enough
b.
Friends often enough
No
10. Is there a friend or relative who could take care of you for a few days?
a.
b.
Yes
No
*11. When you make a decision about something, in general, how do you do it?
a.
By yourself
b.
By yourself after talking to family/friends
c.
Follow advice of family/friends
d.
Let other people make decisions for you
e.
Information unavailable
*12. In rating your health, would you say that it is excellent, good, fair or poor?
a.
Excellent
b.
Good
c.
Fair
d.
e.
Poor
Information Unavailable
13. In the past, how many times have you stayed overnight in a hospital?
a.
Not at all
b.
One time
c.
2 or 3 times
d.
More than 3 times
14. Have you ever stayed in a nursing home, residential care home or other institution?
a.
Yes
b.
No
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Want to
Apply
Clients Initials
15. Do you have the following conditions?
a. Heart problems
Y
N
g. Breathing disorders
Y
N
b. Arthritis
Y
N
h. Cataracts
Y
N
c. Diabetes
Y
N
i. Urinary problems
Y
N
d. Cancer
Y
N
j. Ankle/leg swelling
Y
N
e. Stroke/neurological problems
Y
N
k. Cognitive impairment/dementia
Y
N
f. Mental/emotional condition
Y
N
l. Other
Y
N
*16. If stroke/neurological condition, are you limited in what you can do?
Yes
No
17. How much of the time does bad health, sickness, pain, or disability stop you from doing things you would like to do?
a.
Never
b.
c.
Sometimes
18. Have you fallen in the last 3 months?
a.
d.
Often
b.
Yes
Always
No
19. How often do you go out of the house/building where you live?
a.
b.
Two or more days a week
One day a week or less
20. Do you use a walker or four-pronged cane to get around?
a.
Yes
b.
No
c.
Sometimes
c.
Sometimes
21. Do you use a wheelchair to get around?
a.
Yes
b.
No
*22. Could you please tell me what year it is?
a.
Correct answer
b.
Incorrect answer
*23. What month is it?
a.
Correct answer
b.
Incorrect answer
*24. Where are we now?
a.
Correct answer
b.
Incorrect answer
25. Does client have problems with hearing, vision, or speech that is not corrected with aids such
as glasses, hearing aids, etc?
Aids/Device
Yes
No
Are aids working in order?
a. Hearing
e. Hearing
b. Vision
f. Vision
c. Speech
g. Speech
d. Other
h. Other
Was a referral made?
Yes,
to whom
Yes
No
If no, why a referral was not made
made.
*26. In the past 6 months, have you lost more than 10 pounds without trying?
*27. Do you often feel sad or isolated?
a.
Yes
b.
No
*28. How often do you have contact with persons outside your home?
a.
Yes
b.
No
If yes, referred to:
Daily
Weekly
Monthly
Not often
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Clients Initials
29. How many prescription medications do you take?
Without
Help
30. Can you:
Yes
No
If No, do
you have
help?
Yes
If Yes, is it
enough
ADL IADLS
help?
No
Yes
Comments
No
a) Get around inside your home
b) Bathe
c) Dress
d) Get in and out of bed/chair
e) Use toilet
f) Eat
g) Manage your money
h) Take care of shopping
i) Take your medication
j) Prepare your meals
k) Perform heavy home chores
l) Perform ordinary housework
m) Use transportation
n) Use Telephone
Total number of ADLS
Total number of IADLS
*Record the number of ADLs and IADLs on the Cover Page and number 4 and 5 on the GOEA Score Sheet.
Ask Questions 31 and 32 only if it is determined that the client has limitations in ADLS and / or IADLS.
31. Would you like to talk to someone in detail about wheelchairs, walkers, canes, safety rails, ramp, etc. and other devices
such as speaker phones with large letters?
Yes
No
If yes, referral made to:
Date:
32. Would you like to talk to someone about how your home can be better adapted to
help you get around and perform your daily activities?
Yes
No
If yes, referral made to:
Date:
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Clients Initials
SECTION 3.3 HOME ENVIRONMENT
A. Are any of these problems or safety hazards present in your home?
1. ENVIRONMENT CHECKLIST
Yes
No
a. Dangerous stairs/floors
b. Difficult to get to home entrance
Comments:
c. Difficult to get to bathroom/bedroom
d. Major appliances/toilet not working
e. Problems with heating/cooling
f. Problems getting water/hot
g. Difficulties keeping home free from odor/pests
h. Smoke alarm needed
i. Electrical hazards
j. Poor lighting
k. Unsafe stove
l. Loose/slippery rugs
m. Inadequate locks for doors/windows
n. Difficult to keep home clean/free of clutter
o. Other problems?
2. In case of an emergency, such as a fire, do you think you would be able to get out of your house or apartment
safely?
Yes
No
3. In case of an emergency, such as a fire or fall, do you think you could summon help to your home?
Yes
No
Comments
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Clients Initials
SECTION 3.4 INFORMAL SUPPORTS
1. FOR THE CLIENT
Can you tell me who helps you on a regular basis?
Yes
No
Record information on primary caregiver, as well as other caregivers:
Primary Caregiver
NAME
RELATIONSHIP
ADDRES
PHONE
Day
Eve.
Other Caregivers
NAME
RELATIONSHIP
PHONE
TYPE OF CARE/HELP
Day
Eve.
Day
Eve.
2. FOR THE PRIMARY CAREGIVER
Yes No
Comments
a. Personal care (such as help with bathing, dressing, using
the toilet, getting in and out of bath or eating)
b. Housekeeping (such as help with meal preparation,
cleaning, laundry and taking out the garbage)
c. Transportation
d. Shopping/errands
e. Supervision
f. Taking Medication
g. Managing Money
h. Other, please specify:
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Clients Initials
3. If services were not in place, would there be anything that would make it difficult for you to provide care?
Yes
No
(If yes, discuss and note any factors that might limit caregiver)
Caregiver's comments
Possible factors include:
Yes
No
a. Job
b. Finances
c. Family responsibilities
d. Physical burden
e. Emotional burden
f. Caregiver's mental health
g. Other
Comments
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Clients Initials
SECTION 3.5 MEDICATION REVIEW (OPTIONAL)
A. MEDICATION USE (Ask client if you can see the medications so that you can verify frequency, dosage, etc.
Include over the counter drugs like aspirin, laxatives, and vitamins. Some medicines may be refrigerated)
1. Are you taking any medicines? If so, could you show them to me so we can list their names and dosage?
MEDICATION
PRIMARY
PRESCRIBING
DOCTOR AND
DIRECTIONS /
STRENGTH/DOSAGE
2. Do you have difficulty remembering to take your medications?
a.
Yes
b.
DRUG COMPANY
AND COST
No
(If necessary, prompt the client by asking if s/he is concerned about forgetting. What steps does s/he take to remember?)
3. Please list your drug allergies
4. Referral made
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